Deceased
Jack Hedley Martin
Demographics
76y, male
Date of death
2018-12-07
Finding date
2019-11-21
Cause of death
Sepsis due to pulmonary valve endocarditis and cardiac abscess due to Staphylococcus aureus
AI-generated summary
A 76-year-old man died from sepsis caused by Staphylococcus aureus endocarditis and cardiac abscess. An intravenous cannula inserted during day surgery on 29 November 2018 was not removed before discharge, despite hospital records indicating removal. The cannula became infected, and the patient presented four days later with fever, confusion, and back pain. He died in hospital on 7 December 2018. The coroner found this death resulted from a basic administrative error—failure to remove the cannula—and was wholly preventable. The Tasmanian Health Service implemented system changes to improve discharge procedures for day surgery patients, including verification processes to ensure all medical devices are removed before discharge.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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